Lung/Thoracic Surgery

Author: M. Blair Marshall, MD

WHAT ARE THE LUNGS?
The lungs are organs that allow for gas exchange between the air you breathe and your blood. Oxygen is brought into the body and carbon dioxide is removed. We each have two lungs. The lungs are subdivided into lobes, anatomic divisions. There are three lobes on the right side: upper, middle and lower, and two on the left side: upper and lower. Because the heart is mostly on the left side, the left lung is smaller than the right.

WHAT IS LUNG CANCER?
Lung cancer is an abnormal growth of cells in the lung. This usually starts from a single cell that has undergone a change that allows it to grow in an uncontrolled fashion. Lung cancers can arise from a variety of different types of cells in the lung, thus leading to different types of lung cancers.

The most common types include small cell and non-small cell lung cancers. There are many types of non-small cell cancers, including squamous cell carcinoma, adenocarcinoma, bronchoalveolar carcinoma, large cell carcinoma and carcinoid tumors. They may be discovered at different stages. Depending on the type and stage of lung cancer one has, surgery may be recommended as part of treatment. For detailed information on lung cancer and the staging, please click on these links:

www.cancer.gov/cancerinfo/wyntk/lung 
http://www.cancerindex.org/clinks2l.htm

The American Cancer Society estimates that there will be more than 224,000 new cases of lung cancer diagnosed this year and more than 159,000 patient deaths from lung cancer.

Some patients may become confused about lung cancer. Not every cancer that is in the lung is a lung cancer. Lung cancer is a type of cancer that starts in the lung first. Some patients with other types of cancer may have their cancer spread to the lung. Although this is also cancer and it is in the lung, it is not lung cancer. This is metastatic disease (spread from another type of cancer).

HOW DOES ONE GET LUNG CANCER?
Lung cancer is most commonly associated with smoking. However, certain people may have a genetic predisposition to cancer. Even if you do not smoke, you may be exposed to smoke through your environment. Several workplace substances have also been associated with an increased risk for lung cancer, including arsenic, asbestos, beryllium, silica, radon, etc. Also, patients who do not have normal lungs but have COPD are at increased risk of developing lung cancer.

WHAT TESTS SHOULD I HAVE IF I AM SUSPECTED OF HAVING LUNG CANCER?
Most patients have a chest XRAY which may detect a lung nodule or mass. To clarify this, usually a CT of the chest including the liver and adrenal glands is obtained. One may have additional testing, but these tests are not always required. Other common tests include an MRI of the brain, a bone scan, blood work, or a PET scan. A Pet scan is when radioactive sugar is given to a patient. The sugar will be taken up by cells that are more metabolically active than the other cells. This can commonly occur in cancerous tissue. If an area takes up more of the sugar than the surrounding tissue, this is usually called a “hot spot”. This text does not prove that the nodule is cancer. Many cancers can light up as a hot spot but other processes can light up as well such as areas of infection or granulomatous disease. These are not cancer. Also, not all cancers light up on a PET scan. These tests are all used in conjuction with one another to determine the next best step in your care. If you are not sure what tests are appropriate for you, ask you doctor.

HOW IS LUNG CANCER TREATED?
The treatment of lung cancer depends on a number of factors, the type of lung cancer, the stage, and the condition of the patient. Surgery is most commonly used as part of treatment when the cancer is confined to the chest. If the tumor has already spread to other parts of the body, then surgery usually plays less of a role in the treatment of cancer.

CAN YOU REMOVE PART OF/ OR AN ENTIRE LUNG?
Most of us have enough lung tissue that if we had an operation to remove one or a portion of one lung, we could still breathe and maintain our quality of life. However, many patients with lung cancer are previous smokers and some of these patients may have decreased lung function due to damage caused by cigarette smoke. Although many patients have quite smoking up to several decades before developing a lung problem or lung cancer, the damage done by the smoke never goes away. The majority of patients who develop lung cancer are not current smokers.

How much of the lung that can be removed and maintain a patient’s quality of life is a very important question. Surgeons will usually use a number of tests including some of the following: pulmonary function studies, ventilation perfusion scan, and a six-minute walk test, to determine the impact of any type of chest surgery on a patients breathing after going through such an operation. With this information, your surgeon may be able to calculate how much lung tissue you can afford to do without, if necessary. Most people who have lung surgery do not need to be on oxygen for the rest of their life; however, most patients are placed on it temporarily around the time of their operation.

WHAT IS A BRONCHOSCOPY?
A bronchoscopy is a procedure using a bronchoscope or flexible camera, placed into your airway to view the bronchial tree. This long camera can go into your airway usually through your nose or mouth and then into the trachea. The camera is then placed deeper to look at the branching on your airway. During this procedure brunshings of the inside of the airway or needle biopsies of nodules or lymph nodes actually on the other side of the airway can be done. This may be used to make a diagnosis or it is done for specific therapy. Surgeons commonly perform this procedure on patients who have been put under anesthesia so that the surgeon can look at a patient's airways to confirm expectations prior to surgery.

WHAT IS A MEDIASTINOSCOPY?
Mediastinoscopy
is an operation that is performed most commonly to stage a lung cancer. A surgeon makes a small incision just above a patient's clavicles. Then a mediastinoscope is placed through a small incision just above the clavicles. A mediastinoscope is then placed through the incision along side your trachea, and the lymph nodes that surround your trachea are biopsied. This is commonly done for patients with enlarged lymph nodes wither to figure out the reason for the enlarged lymph nodes or to determining if a lung cancer has already spread to these lymph nodes.

WHAT OPERATION IS PERFORMED FOR LUNG CANCER?
First a diagnosis of lung cancer is established. This may be done by bronchoscopy, a transthoracic needle biopsy or by a video assisted minimally invasive operation. At this point, we will assume that the cancer is localized enough to have surgery play a role. If the lung cancer is early stage, surgery is usually the primary treatment. If the disease is more advanced, patients may be treated with chemotherapy or chemotherapy and radiation therapy before surgery.

For early staged tumors, a minimally invasive approach may be an option. For this, the surgery is done through smaller incisions without spreading the ribs to get into the chest. For more advanced disease or larger tumors, it may be necessary to perform the procedure through an open technique. Most often, surgeons perform either a posterolateral thoracotomy or a muscle-sparing incision to remove a lung cancer. Sometimes the muscles on the back may be divided as part of the procedure or a muscle-sparing incision may be used, If you are about to undergo surgery for lung cancer it is important to ask your surgeon about these approaches and what is best for you.

As part of the planned procedure, you may have an epidural. After you are asleep, the surgeon usually performs a bronchoscopy. Then you may have a mediastinoscopy, to sample the lymph nodes surrounding the trachea. If the lymph nodes have tumor cells in them and they are on the opposite side as the primary tumor, surgery usually does not play a primary role in the management of this stage. If the tumor has spread to the lymph nodes on the same side as the primary tumor, ipsilateral, you may receive neo-adjuvant therapy before having your lung cancer removed. To more clearly understand the issue of lung cancer staging, please visit this website: www.cancer.gov/cancerinfo/wyntk/lung.

Most often, surgeons perform either a posterolateral thoracotomy or a muscle-sparing incision to remove a lung cancer. However, other approaches may be recommended. Sometimes the muscles on the back may be divided as part of the procedure. A muscle-sparing incision may be used, or a minimally invasive approach such as video or robot-assisted operation may be possible. If you are about to undergo surgery for lung cancer it is important to ask your surgeon about these approaches and what is best for you.

As part of the operation for removal of a non-small cell lung cancer surgeons perform a lobectomy, removing a portion of a lung. Occasionally a pneumonectomy, removing the entire lung, may be performed. Once the portion of the lung with the tumor has been removed, the surgeon removes the lymph nodes that receive drainage from the lung. The lymph nodes are examined to determine if the tumor has spread to them; this information will affect the staging of the tumor and hence the prognosis.

After the surgery has been completed, the surgeon will insert one or two chest tubes (drains). These will allow air and fluid to drain out of the chest in the days after the procedure. Once the drainage has decreased, the surgeon will remove the drain. The epidural, if there is one, will be removed. Most patients go home after four or five days in the hospital with the open technique, or 3 days with a video-assisted procedure. While in the hospital, it is important to work on deep breathing and coughing. As with any procedure, there are risks associated with every type of operation. Before having any surgery, make sure you have discussed the potential risks and benefits of your operation your surgeon.

WILL I NEED ANY TREATMENT AFTER SURGERY?
This question is answered once the stage is known. In some patients, the stage is known before surgery, especially in those who get preoperative chemotherapy treatment. These patients usually continue treatment after surgery. In earlier staged disease, the additional information gained from the operation will play a role in determining the need for additional treatment. Usually this is the size of the tumor, if it invades anything, if the lymph nodes have tumor in them, etc.

WHAT TREATMENT IS RIGHT FOR ME?
The type of treatment that is right for you depends on the stage of the lung cancer and cell type. This is an extremely complex discussion. Prior to deciding on what is best for you, you should make sure that you understand the details of the specific treatments as well as the potential risks and benefits to those treatments.

IF I HAVE LUNG CANCER, WHAT IS MY PROGNOSIS?
The prognosis for patients with lung cancer depends very much on the cell type of the cancer and the stage. Some people will have an excellent prognosis, such as those diagnosed with carcinoid, and others will have a less favorable prognosis. For advanced lung cancers of aggressive cell types, the prognosis is poor. You should know all of this information to determine your prognosis and discuss this information with your physicians.

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